|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.92
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.61
|
| Rate for Payer: Dignity Health Senior |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.61
|
| Rate for Payer: Vantage Medical Group Senior |
$1.61
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 69315-184-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Senior |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Senior |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 0054-4496-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.14
|
| Rate for Payer: Dignity Health Senior |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.94
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: Vantage Medical Group Senior |
$1.14
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
NDC 0054-8496-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 69315-184-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET [4398]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 69315-184-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.91
|
| Rate for Payer: Heritage Provider Network Senior |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
|
OP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.73 |
| Max. Negotiated Rate |
$727.06 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$457.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$587.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$727.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$470.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$641.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$127.62
|
| Rate for Payer: Blue Shield of California Commercial |
$51.73
|
| Rate for Payer: Blue Shield of California EPN |
$51.73
|
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$727.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$727.06
|
| Rate for Payer: Dignity Health Senior |
$727.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$547.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.03
|
| Rate for Payer: Heritage Provider Network Senior |
$396.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$408.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$598.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$598.75
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$342.14
|
| Rate for Payer: TriValley Medical Group Senior |
$342.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$309.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$283.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$727.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$727.06
|
| Rate for Payer: Vantage Medical Group Senior |
$727.06
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT [14135]
|
Facility
|
IP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.82 |
| Max. Negotiated Rate |
$641.52 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$461.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.03
|
| Rate for Payer: Heritage Provider Network Senior |
$396.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$309.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$283.21
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
Facility
|
IP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$154.82 |
| Max. Negotiated Rate |
$641.52 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$461.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.03
|
| Rate for Payer: Heritage Provider Network Senior |
$396.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$309.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$283.21
|
|
|
LEUPROLIDE 1 MG/0.2 ML SUBCUTANEOUS KIT. [40814135]
|
Facility
|
OP
|
$855.36
|
|
|
Service Code
|
HCPCS J9218
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.73 |
| Max. Negotiated Rate |
$727.06 |
| Rate for Payer: Adventist Health Commercial |
$171.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$457.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$587.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$727.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$470.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$641.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$127.62
|
| Rate for Payer: Blue Shield of California Commercial |
$51.73
|
| Rate for Payer: Blue Shield of California EPN |
$51.73
|
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Cash Price |
$470.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$393.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$727.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$727.06
|
| Rate for Payer: Dignity Health Senior |
$727.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$547.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$396.03
|
| Rate for Payer: Heritage Provider Network Senior |
$396.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$408.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$154.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$213.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$598.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$598.75
|
| Rate for Payer: Multiplan Commercial |
$641.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$342.14
|
| Rate for Payer: TriValley Medical Group Senior |
$342.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$309.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$283.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$727.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$727.06
|
| Rate for Payer: Vantage Medical Group Senior |
$727.06
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
|
OP
|
$542.03
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.11 |
| Max. Negotiated Rate |
$1,169.86 |
| Rate for Payer: Adventist Health Commercial |
$108.41
|
| Rate for Payer: Aetna of CA Gatekeeper |
$289.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$372.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$233.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$170.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$170.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,169.86
|
| Rate for Payer: Blue Shield of California Commercial |
$460.73
|
| Rate for Payer: Blue Shield of California EPN |
$460.73
|
| Rate for Payer: Cash Price |
$298.12
|
| Rate for Payer: Cash Price |
$298.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$194.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$170.96
|
| Rate for Payer: Dignity Health Senior |
$170.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$346.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$155.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$250.96
|
| Rate for Payer: Heritage Provider Network Senior |
$250.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$172.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$155.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$258.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$178.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$195.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$195.83
|
| Rate for Payer: Multiplan Commercial |
$406.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$216.81
|
| Rate for Payer: TriValley Medical Group Senior |
$216.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$195.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$194.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$170.96
|
| Rate for Payer: Vantage Medical Group Senior |
$170.96
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
|
IP
|
$542.03
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.11 |
| Max. Negotiated Rate |
$406.52 |
| Rate for Payer: Adventist Health Commercial |
$108.41
|
| Rate for Payer: Cash Price |
$298.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$249.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$292.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$250.96
|
| Rate for Payer: Heritage Provider Network Senior |
$250.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$135.51
|
| Rate for Payer: Multiplan Commercial |
$406.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$195.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$179.47
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0093-4148-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0093-4148-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
LEVALBUTEROL CONCENTRATE 1.25 MG/0.5 ML SOLUTION FOR NEBULIZATION (INTERMITTENT) [40856278]
|
Facility
|
OP
|
$6.43
|
|
|
Service Code
|
NDC 9940-8569-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: Adventist Health Commercial |
$1.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.82
|
| Rate for Payer: Blue Shield of California Commercial |
$3.92
|
| Rate for Payer: Blue Shield of California EPN |
$3.14
|
| Rate for Payer: Cash Price |
$3.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.47
|
| Rate for Payer: Dignity Health Senior |
$5.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.98
|
| Rate for Payer: Heritage Provider Network Senior |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.57
|
| Rate for Payer: TriValley Medical Group Senior |
$2.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.47
|
| Rate for Payer: Vantage Medical Group Senior |
$5.47
|
|
|
LEVALBUTEROL CONCENTRATE 1.25 MG/0.5 ML SOLUTION FOR NEBULIZATION (INTERMITTENT) [40856278]
|
Facility
|
IP
|
$6.43
|
|
|
Service Code
|
NDC 9940-8569-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$4.82 |
| Rate for Payer: Adventist Health Commercial |
$1.29
|
| Rate for Payer: Cash Price |
$3.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.35
|
| Rate for Payer: Heritage Provider Network Senior |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.61
|
| Rate for Payer: Multiplan Commercial |
$4.82
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.27
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154435]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.22
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 71093-144-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 71093-144-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 31722-574-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 31722-574-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
LEVETIRACETAM 1,500 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [154436]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
